Study Questions:

Is there an impact of appropriate use criteria (AUC)-based education on ordering outpatient transthoracic echocardiograms (TTEs) by physicians-in-training?

Methods:

A randomized control trial was performed in which internal medicine and cardiology physicians-in-training were randomized to an AUC-based educational intervention or to a control group at an academic medical center in Boston, MA. The intervention included a lecture highlighting AUC for TTE; an electronic pocket-card including “tips” on appropriate ordering of TTE; and individualized monthly feedback reports detailing the number of appropriate, inappropriate, and uncertain TTEs ordered using the 2011 AUC. The primary endpoint was the rate of inappropriate versus appropriate TTE using the same AUC.

Results:

For cardiology physicians-in-training, the proportion of inappropriate TTE was significantly lower (13% vs. 34%, p < 0.001) and the proportion of appropriate TTE was higher (81% vs. 58%, p < 0.001) in the intervention group than in the control group. The odds of ordering an appropriate TTE in the cardiology intervention group was 2.7 (95% confidence interval [CI], 1.5-5.1; p = 0.002) relative to the control group. The internal medicine physicians-in-training ordered a small number of TTE overall, and there was a trend toward ordering an appropriate TTE in the intervention group relative to the control group (odds ratio [OR], 8.1; 95% CI, 0.95-69; p = 0.055). Six clinical scenarios accounted for 75% of all inappropriate TTE, with the three most common inappropriate indications being routine surveillance (<1 year) of known cardiomyopathy without a change in clinical status, routine surveillance of known small pericardial effusion, and routine surveillance of ventricular function with known coronary artery disease and no change in clinical status.

Conclusions:

The authors concluded that in cardiology fellows with a high rate of ordering inappropriate TTE, an AUC-based educational and feedback intervention reduced the proportion of inappropriate and increased the proportion of appropriate outpatient TTE.

Perspective:

There are a number of means to alter human behavior; authoritative instruction to a vulnerable group accompanied by regular feedback using words like ‘appropriate’ and ‘inappropriate’ not surprisingly modifies behavior, as it did in this study. If this study succeeds in demonstrating that education and feedback alter behavior; it does not address the appropriateness of the AUC, patient outcomes, or alternative learning methods including trainee supervision.